Observations
Citation Text for Tag A029, Regulation NEH8
Scott, Kevin K.
Based on a review of the facility's census for active Outpatient Drug-Free patients on August 21, 2014, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum capacity of patients.
The findings include:
On August 21, 2014, the Licensing Specialist reviewed the facility's census for active Outpatient Drug-Free patients. The facility's authorized maximum capacity for Outpatient Drug-Free patients is 75. However, based on the facility's census for active Outpatient Drug-Free patients, the total number of active Outpatient Drug-Free patients in the facility was 95. The facility exceeded their authorized maximum capacity for the Outpatient Drug-Free licensed activity by 20 patients.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Outpatient clients in excess of our drug free maximum capacity of 75 are being referred to local providers based on funding, geographic location and patient preference. This will be completed by October 15, 2014 and is being supervised by the CAD Clinical Supervisor. To ensure compliance, the Clinical Supervisor will monitor census weekly via group and individual supervision for compliance with current maximum capacity limits. Once compliant the Project Director will petition DDAP for an increase in our drug free patient maximum capacity. |